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Providers of Independent Medical Evaluations

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Medical Evaluation Referral

Referral of a Client for a Medical Assessment

Alliance of Clinical Evaluators - Client Referrals.
By completing the following on-line medical evaluation client referral you will help us better understand your requirements with respect to the client you are referring to us.
Please be sure to provide us with as much detail in the appropriate fields.

Thank you for your referral!

Client Referral Form

Please complete the following information form.
Please be sure to provide us with as much detail as possible in the appropriate fields.
Required fields are denoted with a red asterisk '*'.

Type of Claim

Other Claim Type from above

Referral Source

Claim Representative:
Contact Person:

Claim Number:

Referring Insurance Co. :
Corporate Name:

Name of Insurer:
(if different than above)

Address:

City:

Postal Code:

Phone #

* xxx-xxx-xxxx

Fax #

Evaluee Information

Surname:

Given Names:

Gender:

male

female

Date of Birth:

Date of Loss:

Address:

City:

Postal Code:

Home Phone #

* xxx-xxx-xxxx

Work Phone #

Diagnosis:

Benefit
Being Claimed
(Auto Insurance)

Specify Other Benefit Claim

Occupation
Being Claimed

Any Occupation

Specific Occupation (specify below)

Specify Other Specific Occupation

Employer Information

Occupation:

Company:

Contact Person:

Address:

City:

Postal Code:

Phone #

xxx-xxx-xxxx

Fax #

Legal Representative of Evaluee (if applicable)

Firm:

Contact Person:

Address:

City:

Postal Code:

Phone #

xxx-xxx-xxxx

Fax #

Specific Evaluator Required

Other Evaluator

Other Services Required

Translator:

NoYes Language

Transportation:

NoYes

Specific Questions to be Addressed by the Evaluator

Please choose from amongst the questions listed below and/or send us your specific questions to be addressed in the text box at the end of this list of questions.
Within the scope of your medical/professional discipline, are the goods and services detailed in the OCF-18 or OCF-22 in question reasonable and necessary as a direct result of injuries sustained in the accident? Please provide a detailed rationale and supporting evidence with your response. If in your opinion these services are not required, please provide details as to any other medical/ rehabilitation the individual may require as a direct result of injuries sustained in the accident?

Within the scope of your medical/professional discipline, does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident for which you would recommend an informal treatment program, i.e. structured gym program, self-directed gym program, lifestyle changes, etc. If so please provide details for any recommendations made.

Within the scope of your medical/professional discipline, does the claimant suffer from any medical condition that existed prior to the accident and has this been exacerbated as a result of the accident? If so, to what extent? If present, how might this condition affect the recovery from injuries sustained in the accident?

Within the scope of your medical/professional discipline, what is the claimant’s prognosis?

Within the scope of your medical/professional discipline, what are the claimant’s diagnoses?

Within the scope of your medical/professional discipline, does a disability exist as a result of the accident? If so, please outline the evidence to support your opinion and the current restrictions as a result.

As a result of the accident, In your medical/professional opinion, does the claimant suffer a substantial inability to perform the essential tasks of his/her:

Pre-accident employment?
Housekeeping and home maintenance?
Caregiving duties?
Activities of daily living?

In your professional/medical opinion, does the claimant require attendant care assistance as a result of the accident? If so list the activities and the duration for which this will be required.

In your professional/medical opinion, has the claimant reached maximal medical recovery?

Within your professional/medical discipline, are there any further recommendations you would indicate to return the claimant to better function?

Within the scope of your medical/professional discipline, does the claimant suffer a complete inability to carry on a normal life as a direct result of the accident?

In you medical/professional opinion, does the claimant suffer an impairment as a result of the accident that prevents him/her from driving, riding as a passenger and/or taking public transportation?

Within the scope of your medical/professional discipline, does the claimant suffer a complete inability to engage in any employment for which the claimant is reasonably suited by education, training or experience?

Are there any additional diagnostic tests or clinical information required in order to complete your diagnosis?

Other
Please detail any additional questions you would like the evaluator to address

Specific Questions for Functional Abilities Evaluations

Primary FAE questions:

In your medical/professional opinion, what is the employee/claimant’s current functional ability?

Within the scope of your medical/professional discipline, does a functional limitation exist as a result of the accident/incident? If so, please outline the evidence to support your opinion and the current functional limitation(s) as a result.

Is the employee/claimant able to perform the essential functional tasks of the pre-accident employment?

Secondary FAE questions:

Within the scope of your medical/professional discipline, are there any further recommendations you would indicate to return the employee/claimant to better function?

In your medical/professional opinion, does the employee/claimant suffer a functional limitation as a result of the accident that prevents him/her from ?
Other
Please detail any additional questions you would like the Functional Abilities Evaluator to address

Confirmation of Assessment

Preferred Method
of Communication

Telephone

Fax

46 Jackson St. East, Hamilton, ON L8N 1L1 Canada - Tel: 905-777-0223 - Email: info@acemedicalexams.ca

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